A training resource for medical staff leaders and professionals
Medical
Staff
Briefing
Volume 23
Issue No. 6
P5
Locum tenens
P9
The RFNA who is also an APN
P11
Maximizing interview skills
P12
Who needs departments anyway?
While locum tenens can solve all manner of staffing challenges, using shortterm medical staff members comes
with a set of potential problems—but
they can be worked around with the
right preparation. Learn how inside.
Patricia A. Furci, RN, MA, Esq., and
Samuel J. Furci, MPA, take a look at
establishing the appropriate credentialing
process for these staff members.
Guest columnist Kathleen Tafel offers
tips on improving a core skill for medical staff professionals.
William K. Cors, MD, MMM, FACPE,
continues his ongoing series on medical
myths by taking a look at membership,
privileges, and rights and responsibilities.
June 2013
Dissolving a department
One organization’s medical staff structure
­transformation
How is your medical staff broken down? Does your organization have
a multitude of departments? Are you limited to medical and surgical
­departments only, with smaller breakdowns within those ­departments? Or
do you have something in between?
Now ask yourself what would you do if your organization needed to make
a major change to its structure. What if you needed to eliminate an entire
department and absorb its components into other departments? Where
would you begin?
This is exactly the challenge one Washington hospital faced when it
discovered its existing medical staff structure was causing more problems
than it solved.
Yakima Regional Medical Center & Cardiac Center had, until this
year, a three-department system: medicine, surgery, and cardiopulmonary. This structure had existed since 1996, created at the request of the
medical staff. The cardiac and thoracic surgery physicians had pushed
for their own departmental structure, and the organization worked with
them to set it up.
“We have a significant heart program here,” says Rita Murphy,
CPCS, CPMSM, medical staff services manager for Yakima Regional.
“Our lead cardiothoracic surgeon had wanted to develop a department
Trendspotting
LD chapter
The location within the Joint Commission
manual where relevant requirements and
standards relating to locum tenens use can
be found.
April 8
The release date of a letter to CMS
questioning proposed rule changes for
medical staff policies.
2020
The cutoff year by which RN first assistants
must have baccalaureate degrees in
addition to all other required training.
Medical Staff Briefing
This document contains privileged, copyrighted information. If you have not purchased it or are not otherwise
entitled to it by agreement with HCPro, any use, disclosure, forwarding, copying, or other communication of the
contents is prohibited without permission.
editorial advisory board
Assoc. Editorial Director
Todd Hutlock
Contributing Editor
Matt Phillion
[email protected]
Alpesh N. Amin, MD,
MBA, FACP
Executive Director
Hospitalist Program
Vice Chair for Clinical
Affairs & Quality Dept.
of Medicine
University of California, Irvine
Sally Pelletier,
CPMSM, CPCS
Senior Consultant and
Director of Credentialing
Services
The Greeley Company
Danvers, Mass.
Michael Callahan, Esq.
Katten Muchin
Rosenman, LLP
Chicago, Ill.
William K. Cors,
MD, MMM, FACPE
Chief Medical Quality
Officer
Pocono Health System
East Stroudsburg, Pa.
Sandra Di Varco
McDermott Will &
Emery, LLP
Chicago, Ill.
Roger A. Heroux,
MHA, PhD, CHE
Founding Partner
Hospitalist Management
Resources, LLC
HMR ED Call Panel
Solutions
Pensacola Beach, Fla.
Jonathan Lovins,
MD, SFHM
Hospitalist and Assistant
Clinical Professor of Medicine
Duke University Health System
Durham, N.C.
William H. Roach
Jr., JD
McDermott Will & Emery
Chicago, Ill.
Richard E. Rohr, MD,
MMM, FACP, FHM
Director of Hospitalist
Programs
Guthrie Healthcare System
Sayre, Pa.
Jodi A. Schirling,
CPMSM
Alfred I. duPont Institute
Wilmington, Del.
Richard A. Sheff, MD
Principal and Chief
Medical Officer
The Greeley Company
Danvers, Mass.
Raymond E. Sullivan,
MD, FACS
Waterbury Hospital
Health Center
Waterbury, Conn.
Quick Hits
Online
From the field
Hospital groups question
medical staff rule from CMS
“[The departmental turf
battle] was beginning to
impact the OR ... because of
conflicts between cardio and
surgery.”
Several hospital groups are objecting
to a CMS proposal that would “remove
the ability of hospital systems and their
medical staffs to make their own determinations about the optimal medical staff
framework” and prevent integration of
medical staffs in multihospital ­systems.
The groups released an April 8 letter asking that CMS provide a convincing reason
for the necessity of the policy. The groups
argue that ­individual hospital systems are
best able to determine whether to have
an integrated medical staff or to have
­separate medical staffs at each facility,
and that CMS should not regulate this.
Source: Medical Staff Leader Insider (www.
hcpro.com/MSL-291243-871/Hospital-groupsquestion-medical-staff-rule-from-CMS.html).
NAMSS asks CMS for
­clarity on privileging,
staff questions
The association calls on CMS to consider
hospital registered dietitian privileges and
more in its final policy.
Source: Credentialing Resource Center Insider
(www.hcpro.com/CRD-291052-863).
Medical Staff Briefing (ISSN: 1076-6022 [print]; 1937-7320 [online])
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Questions? Comments? Ideas?
Contact Contributing Editor Matt Phillion
at [email protected].
Rita Murphy, CPCS, CPMSM
“We worked really closely
with medical staff leadership,
letting them know what the
bylaws are, what the MEC is
allowed to do, as well as the
board, and what revisions
would look like.”
Rita Murphy, CPCS, CPMSM
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Medical Staff Briefing
more on a service line basis with a team orientation.
He worked to create a ­cardiopulmonary department
to exist alongside our regular medicine and surgery
departments.”
Challenges began to arise, however, due to a disconnect between departments in key areas such as privileging, proctoring, policy development, and development
of service lines.
“It became exclusionary of interdepartmental discussion,” says Murphy. For example, the hospital
didn’t take into account how some of the changes that
­affected the cardiopulmonary department would affect
the medicine or surgery departments.
Over time, the cardiopulmonary department stopped
appearing to be in alignment with the rest of the medical staff.
“They had kind of siloed themselves,” says Murphy.
The medicine and surgery departments were initially
fine with the split, as long as their own activities and
actions were not negatively impacted. As time went on,
though, that impact began to be felt. The pivotal moment came with anesthesiologist privileging.
“Our cardiology anesthesiologists were separated
from general anesthesia, and not part of general
surgery,” says Murphy. This turned into a huge turf
battle—it was the straw that broke the camel’s back and
created medical staff dissension.
“It was beginning to impact the OR, particularly the
scheduling of cases because of conflicts between cardio
and surgery,” says Murphy.
So the problem was noted, but what was the next step?
Dissolving a department 101
Murphy began researching how other medical staff
departments had gone about the restructuring process.
“It’s not something that you just suddenly do,” she
says. “I wanted to see what other facilities had done.”
However, there weren’t many examples for her to
draw from, and although Murphy found examples of
restructuring due to insufficient staff—low department membership requiring a small department to be
absorbed into a larger department, for one—she had
a more difficult time finding examples that dealt with
restructuring due to ­conflicts.
“Ours was more because of the political environment,” she says. “What we had was rather unique.”
Fortunately, hospital leadership was on their side.
“We worked really closely with medical staff leadership,
letting them know what the bylaws are, what the [medical executive committee (MEC)] is allowed to do as well
as the board, and what revisions would look like,” says
Murphy. “What are the positive sort of benefits that
would accompany a departmental restructuring? That
was our role.”
Not only was the problem unique, the setup of the
departmental structure was unique as well—the organization did not use a traditional departmental layout.
“Part of a new program we are doing at the hospital
is providing leadership education to incoming officers—
I think it is extremely pivotal to help empower them
with knowledge for their role,” says Murphy. “Prior to
having this program, it was a lot of just filling the role
without fully understanding it.”
Although Yakima doesn’t have a closed medical
staff, it can at times feel that way—the hospital didn’t
previously have a lot of new physicians coming into
the community. But recently, Yakima has had an
influx of new blood; these newer physicians were able
to bring their experiences into the discussion, showing
the staff that the existing structure had an “elite” feel
to it.
“As the medical staff, there are things that they can
do to improve the environment, and so having new
blood with experiences and backgrounds from other
successful programs meant they were able to provide
examples and resources for how things were structured
elsewhere,” says Murphy. “They weren’t having the
same issues we were having.”
It was also a situation, the MEC noted, where the
issues could not be autonomously resolved—there had
been ongoing disagreements on how often departments would meet and what their privileging requirements were, and so some sort of outside mediation was
required.
The MEC sat down with representatives from all the
departments to discuss the situation. The credentialing
committee was represented as well to discuss how the
situation had impacted its role.
“It was very different to see how all the different
departments weighed in,” says Murphy. “They spoke
about how very directly they were affected by the
­department over time.”
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Medical Staff Briefing
Finally, the MEC voted to restructure the cardiopulmonary department—specifically, to reabsorb it into
the medicine and ­surgery departments—as a way of
alleviating the problems.
Rapid change
The pace at which the change happened was set
almost accidentally, Murphy says. The discussion was
presented, deliberated, and turned into a vote right
at the MEC meeting rather than allowing months of
discussion and deliberation. This turned out to be a
blessing in disguise: Since the dissolution of the cardiopulmonary department was meant to resolve the
high levels of animosity and argument, the immediate
decision worked to quash the negative culture that had
developed.
Restructuring for any reason, Murphy notes, tends to
work better if it happens quickly.
“What I’ve heard from other organizations going through a restructuring is that it’s like taking off
a Band-Aid—faster is better,” she says. “The ­bigger
you build it up, the more talk you will have about it
and the more roadblocks it creates. It grows out of
control.”
It was also very important to leadership to make the
change quickly so there would be more time to acclimate staff to the transition and facilitate recruitment
efforts.
“They wanted to be able to build on the end of it, to
spend more time helping members develop their sections and develop an identity within the department,”
says Murphy.
The organization expects the restructuring will present more growing pains in the future. There are some
dissenting voices who are unhappy with the change,
and the alterations to communication have had an impact on nursing—who, even though they interact with
physicians constantly, are not fully aware of the inner
workings of the medical staff.
“It’s difficult because nursing doesn’t know the structure of the medical staff—they become concerned and
nervous because there has been a large change,” says
Murphy.
Yakima also expects a bit of pushback on the part of
the physicians. Some have stepped forward to ask how
they can reevaluate the bylaws and understand the
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hcpro.com June 2013
­appeals process.
“It’s interesting that we might be going through the
appeals process,” says Murphy. “The Joint Commission
expects you to have a mediation process if the medical
staff disagrees with MEC actions.”
The primary reaction among the medicine and
surgery departments, Murphy notes, has been one of
relief.
“A lot of these physicians were fine with the
departments the way they were as long as they left
them alone—but it’s been interesting where they’re
saying, ‘This is finally done, we can get back to focusing on medicine and surgery,’ ” says Murphy. “We’re
all a big group rather than having this exclusive
department.”
The area most impacted, of course, is anesthesia, as
all anesthesiologists—cardiovascular and otherwise—
are now under the same leadership umbrella.
“We’re slowly moving in the right direction and
the departments are feeling freer,” says Murphy.
“Everyone needs to be on board and on the same
page. I’ve heard over the weeks that it’s a hospital
decision, or that it’s an administrative decision, but
these were elected peers, elected to represent the
medical staff.”
The decision may have had the support of the Csuite, but it came from and was implemented by the
medical staff itself. The executive leadership—the CEO,
CNO, and COO—were not part of the discussion to
restructure the departments.
“It was a sensitive and emotional decision,” says
Murphy. “But as a medical staff coordinator, it was
­inspiring to see the physicians working together
this way to improve themselves and to grow as an
­organization and group.”
It certainly was not a comfortable decision, either—
the vote was taken in with leaders of the cardiopulmonary department in question, and there are still some
issues to be resolved to get everyone on the same page
in anesthesia.
“Now ... the leverage is there to have the anesthesia
group function as one unit, with one section chair over
them, holding them accountable and responsible,” says
Murphy. “It will cause changes, but ultimately it will
result in a smoother anesthesia service line for patients,
surgeons, and quality of care.” H
© 2013 HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or 978-750-8400.
Medical Staff Briefing
Locum tenens: Minimize risks by doing
your homework
Many organizations across the country make use of
locum tenens, but the role and requirements for these
temporary physicians has evolved and changed over
the decades. What is the best way to handle locum
tenens who return for repeat assignments? How do you
ensure that you retain the ability to sever ties with a
locum tenens on your terms if you need to?
One organization shares its story about maximizing
the beneficial use of locum tenens without tying its own
hands through overly limiting policies.
“Like many communities, we episodically have needs
for temporary staff in certain specialties,” says Bev
Osborne, CPMSM, director of medical staff services
at Providence Sacred Heart Medical Center (PSHMC)
in Spokane, Wash.
Even though the best recommendation is to avoid
­using locum tenens as much as possible, sometimes
they are necessary. So what is the optimal way to efficiently manage these physicians?
It’s possible, Osborne says, to appoint repeat locum
tenens on the medical staff as associate members. “If a
locum tenens physician completes an ­extended or repeat assignment and a high quality of care is observed,
this can be an effective thing to do,” she says.
But this decision is not without its risks. If you place
a physician on active or associate staff, then determine
that his or her quality of care or behavior is not to the
standard of the institution, you will not have the ability
to terminate the relationship without a potential fair
hearing. Meanwhile, most bylaws or credentialing policies will allow organizations to immediately terminate a
locum tenens provider in the event that issues of quality, behavior, or compliance with policies arise.
“The locum tenens concept is inherently less stable
than full medical staff membership—they are credentialed and privileged, but because of the immediate
need, they may not be as deeply vetted as a permanent
staff member, and while there are many quality locum
tenens, our experience is that the locum tenens community at large has more issues than those recruited
by one of our medical groups and applying for full
staff privileges,” says Osborne. “Hospitals need the
ability to sever ties with a locum tenens physician, if
needed.”
Finding the best
Osborne notes that if you come across a particularly
problematic locum tenens applicant, you should closely
analyze subsequent locum tenens applicants in that
same specialty.
“It appears to us that the nationwide pool of quality locum tenens applicants in specific specialties can
get particularly shallow,” she says. “In one instance,
we did not accept three applicants in a row in a certain
specialty—one of these applicants was even under a
current investigation in another state for poor patient
care, poor recordkeeping, and behavior.”
But it’s also possible to find and work with excellent locum tenens—these are the ones who could
potentially be considered for associate medical staff
appointments.
“There are some physicians who use locum tenens
work to check out different parts of the country and
decide where they want to settle down and practice,”
says Osborne. “For some adventuresome spirits, it’s a
great lifestyle choice; I recall one who had worked in
Alaska in the summer and Hawaii in the winter, with
plenty of free time in between. Another reliable source
of locum tenens: nearby medical school or university
settings. These physicians often make excellent locum
tenens candidates, particularly for episodic short-term
assignments.”
Military physicians may also be a good option. They
have leave time, or may be at the end of their military
obligation and deciding where they want to practice,
says Osborne.
“One of my family members was managed by a
locum tenens military physician a few years back,” she
says. “In visiting with him, I learned that he’d agreed
with his wife to perform locum tenens work in the two
areas they were considering to move after his separation from the military.”
After spending a few weeks in each location, the couple made the decision to live closer to the physician’s
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June 2013 hcpro.com
5
Medical Staff Briefing
wife’s family, but during the physician’s time in Spokane he took great care of Osborne’s family member.
Screening questionnaire
“There are many good reasons that physicians elect to
work as a locum tenens; however, some locum tenens
applicants are seeking this avenue because, for a variety
of reasons which may include quality and/or behavior,
they cannot find a permanent position,” says Osborne.
After two incidents in which locum tenens applicants were not accepted in the final days before groups
had hoped to use their services, PSHMC developed a
screening tool that it now provides to the locum tenens
agency ahead of time to demonstrate how stringent its
vetting process will be.
“We ask the normal attestation questions from our
standard application, such as if they have ever had privileges revoked or if they’ve had any licensing issues,”
says Osborne. “By asking these questions up front as
part of our screening tool, the locum tenens company
will likely move on to the next candidate if they can see
a poor likelihood of our accepting the candidate they
are offering.”
In one of the instances where PSHMC turned down
a locum tenens candidate, the ­applicant had repeatedly
delayed providing information to the hospital. Ultimately, it was discovered that he had been terminated
from a prior hospital’s staff, a fact he had not disclosed.
“In retrospect, we feel his delays were in hopes that
we would not discover the facts—or that we would be so
in need of his services over the Christmas holidays that
we would overlook his false attestation,” says Osborne.
“We do not believe the locum tenens agency was aware
of this issue, but we also never assume that a locum
tenens agency has fully vetted a physician to the same
level we do.”
Regardless of how the screening questionnaire is answered, PSHMC still performs primary source verification of key elements in the credentialing process.
Set your standards
Keep in mind that not every candidate presented by a
locum tenens company will meet the hospital standards.
“Locum tenens companies’ primary goal is to place
physicians; hospitals’ primary goals are patient safety
and quality,” says Osborne.
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hcpro.com June 2013
PSHMC continues to refine expectations for locum
tenens. One question being debated is whether current
board eligibility or certification should be a requirement for all locum tenens—a number of experienced
physicians who want to scale back their work schedules
wish to perform locum tenens for a few years following
a full-time practice.
“We may consider accepting experienced locum
tenens for a very short period following a lapse in certification. We don’t want to automatically exclude those
who might prove to be a great fit for us,” says Osborne.
The associate staff member
PSHMC still uses the associate medical staff member
concept in select instances when a repeat ­locum tenens
practitioner has proven to be a reliable and valuable
resource for the organization.
“We perform an evaluation following each locum tenens
assignment; the group which has brought in the locum
tenens must be a part of that evaluation,” says Osborne.
That evaluation looks at how long the practitioner was
at the organization, his or her interactions with hospital
and medical staff members, and patient care outcomes.
That said, the organization’s policies and procedures
provide a lot of flexibility. There are no set time frames
or number of assignments that automatically dictate
whether a physician should be made an associate medical staff member following locum tenens work.
“Sometimes you have someone who comes in solidly
for three months, sometimes you have someone who is
in episodically, others regularly for a week every month.
We evaluate them on a case-by-case basis before considering appointment to associate staff,” says Osborne.
Evolution of locum tenens
The role of locum tenens has grown over the years
from something relatively informal to a natural part of
the healthcare industry.
“It used to be that a specialist would find a locum
tenens to staff his or her practice for a much needed
vacation or recovery from surgery—that’s where the name
comes from, to ‘hold the place of,’ after all,” says Osborne.
“But now because the industry has developed shortages in
certain specialties for periods of time, we’re not just
replacing one physician temporarily but augmenting the
staff. The role of locum tenens has changed.” H
© 2013 HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or 978-750-8400.
Medical Staff Briefing
Locum tenens FAQ
If your healthcare organization is looking to fill a short-term
u­ses. It is typically a term recognized and used by t­raveling
need, the solution may come in the form of a locum tenens.
­physicians who fill an institution’s need for a particular
This temporary staffing solution allows the organization to
­specialty or ­subspecialty for a specific time. All practitioners
­provide its community with continuity of care while undergoing
with ­temporary privileges are not considered locum tenens
an internal period of transition.
in part because temporary privileges may also be grant-
MSPs can help with this transition period by familiarizing
ed to new ­applicants who are awaiting staff appointment
themselves with the finer points of the locum tenens industry.
and privileges. Practitioners who are locum tenens usual-
­Although your organization may follow a standard operating
ly have temporary privileges, although this is not always the
procedure when it comes to locum tenens, there are ways to
case, depending on the length and frequency of their work
improve efficiency and continuity.
assignment.
Can medical residents moonlight as locum tenens?
Did you know advanced practice professionals
The Accreditation Council for Graduate Medical
­Education (ACGME) has strict guidelines that govern the
(APP) and hospitalists are in demand as locum
tenens?
patient care ­activities residents engage in outside of their
Just as more hospitals are employing hospitalists and
educational ­programs. ACGME uses the term “moon-
­
lighting” to describe this type of work. Residents can
ferred to as AHPs or physician extenders), so too are these
moonlight internally at the sites used by their educational
changes reflected in the locum tenens field. Organizations
program, or they can moonlight externally at other loca-
find hospitalists beneficial because of the amount of time
tions, where they may be considered ­locum tenens by the
they can spend in the hospital making rounds and seeing
host facility.
patients.
expanding the scope of services for APPs (sometimes re-
If your organization’s bylaws and other documents
that ­define qualifications for membership and privileges
Are locum tenens accountable for proving
allow it, hospitals may find it advantageous to use a
­competency no matter how short their term?
resident as a ­locum tenens because the organization
may be in a position to bring the practitioner back in a fellowship or full-time staff member role after his or her program ends.
These practitioners can assimilate into the medical staff
faster than other new hires because of their past work
­experience at the organization and familiarity with coworkers
and policies.
Additionally, MSPs may find they can expedite the
­credentialing process for these practitioners because they
­already conducted similar checks when they processed the
practitioners’ locum tenens applications.
Are all practitioners with temporary privileges
­considered locum tenens?
Joint Commission standards require that ­organizations have
plans for evaluating the competency of practitioners who are
granted clinical privileges. Organizations should use the same
methodologies to determine ­competency, such as ­focused
professional practice evaluation and ­ongoing ­professional
practice evaluation, as they do for other ­practitioners granted
privileges.
Organizations should tailor the monitoring methods
as ­appropriate to the locums’ time at the facility and their
­particular specialty area of practice. This may negate the use
of direct observation for these individuals due to their ­limited
time. The situation may lend itself to utilizing retrospective
chart review, the results of which would also help to determine
whether the organization would want that practitioner to return
to their facility.
No. Locum tenens is a Latin term for “placeholder” and
is not one that The Joint Commission (formerly ­JCAHO)
As challenging as this may seem, medical staffs
can ­tailor existing requirements to fit this unique population.
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June 2013 hcpro.com
7
Medical Staff Briefing
Locum tenens FAQ (cont.)
For ­example, they can solicit more references for
MSPs can also reap time-­saving benefits by selecting
locum ­tenens than other practitioners and initiate chart
a locum tenens agency with an ­internal CVO. Although
review once the locum tenens begins ­working in the
there may be additional fees ­attached to this service, it
organization.
can be advantageous ­because the service may ­expedite
the credentialing process and allow the MSP to ­focus
Do locum tenens staffing agencies evaluate the
on other responsibilities. The Joint Commission ­accepts
medical staffs with which their practitioners
the verifications conducted by this third party if certain
­contract?
­requirements are met.
Even if a locum tenens agency does not contain a CVO,
For a hospital’s continued success, it is important
that the organization maintain a good reputation in the
it may regularly conduct credentialing-like activities on its
community with ­patients and providers. MSPs are used
practitioners.
to investigating a ­practitioner’s credentials. At the same
Locum tenens resources on the Web
time, however, those practitioners are evaluating the
healthcare facility, the medical staff, and even the MSP
When your organization asks you to help research its
to determine whether they actually want to work at the
­locum tenens options, the following are some websites to
organization.
guide you:
It is not uncommon for practitioners to share their opin-
• www.nalto.org. The National Association of ­Locum
ions about an organization with their peers. However, if these
­Tenens Organizations’ (NALTO) website is filled with
practitioners work with a locum tenens staffing agency,
general information about the locum tenens ­industry,
chances are their agency is keeping formal records of those
­including the most recent news and regulations.
opinions and using them as a screening tool to help decide
­However, the most valuable resource for MSPs is
which hospitals to work with in the future. This makes it even
­undoubtedly the member contact directory, which lists
more important for the medical staff department to put its
email addresses and phone numbers for NALTO
best foot forward.
­members. You can use this list to begin your search
Nevertheless, these evaluations take into consideration
­issues that are more substantial than whether a practitioner
likes a ­hospital. For example, they also evaluate such factors
as quality of care and how well the organization follows its
own policies.
for a locum ­tenens or use the contact information to
verify an applicant’s work history with one of these
organizations.
• locumlife.modernmedicine.com. LocumLife is a magazine dedicated to locum tenens physicians. If your organization wants to eliminate the need for staffing agencies
Do locum tenens staffing agencies serve as a
and contact locum tenens directly, it can place an ad in
­credentialing verification organization (CVO) for
this magazine.
• www.jointcommission.org. Although The Joint
the practitioners they provide?
One of the benefits enjoyed by medical staffs ­working
­Commission does not use the term “locum tenens,” its
with a locum tenens agency is that the staffing agen-
website provides locum tenens–related information, in-
cy ­pre-­selects ­candidates, thereby cutting back on the
cluding topics such as ­temporary privileges and health-
time the ­medical staff spends on candidate screening.
care staffing services.
Source: Assessing the Competency of Low-Volume Practitioners: Tools and Strategies for OPPE & FPPE ­Compliance, Second
­Edition, published by HCPro, Inc.
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hcpro.com June 2013
© 2013 HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or 978-750-8400.
Medical Staff Briefing
When the RFNA is also an APN
Determining appropriate credentialing processes
by Patricia A. Furci, RN, MA, Esq., and Samuel
J. Furci, MPA, of Furci Associates, LLC, in West
Orange, N.J.
As we have noted in a prior article, there are multiple
midlevel practitioners crowding around the operating room table, with one profession standing out amid
these often confusing and blurred roles—the ­RN first
assistant, otherwise known as the RNFA.
An RNFA is an experienced perioperative (operating
room) nurse who has completed advanced education
and performs within a specific scope of practice in order
to optimize quality care for patients undergoing surgery.
However, sometimes the RNFA may also be an advanced
practice nurse (APN), so how does the medical staff office handle the processing of his or her application?
Background
According to Brown and Draye, authors of “Experiences
of Pioneer Nurse Practitioners in ­Establishing Advance
Practice Roles” (2003), a central theme in their research
of pioneer nurse practitioners was that of building on
existing autonomy and making a difference in patient
care. APNs who desire to practice in the role of assistant
at surgery are likely to have these essential intentions.
Clearly, the nurse who acts as first assistant takes on a role
of autonomous decision-making and critical thinking.
While the nurse is working under the guidance of a
surgeon, the knowledge and skills required of the first
assistant are not subservient to or always at the order
of the operating surgeon. There is an inherent expectation that the RNFA, whether an APN or experienced
perioperative nurse, be educated to not only know the
steps of the surgical intervention, but to also know, for
example, the anatomic location of critical structures,
physiologic consequences of various methods of handling tissue, hemostasis, and how to anticipate needs
without instructions or direction.
Clearly, to assume such a knowledge-based and technically challenging role, APNs without any operating room
­experience need to acquire fundamental ­knowledge and
skills to safely perform as a first assistant.
The role of the RFNA doesn’t change
According to the Association of periOperative Registered Nurses (AORN), the RNFA is an experienced
operating room nurse who has completed additional
formal education. When an APN is requesting to
become a member of a hospital’s medical staff as an
RNFA, the role doesn’t change. This unique position
encompasses all phases of surgical care—from the
time the patient enters the hospital until the time of
discharge.
The role of the RNFA in surgery and the delineation
of privileges (DOP) may include assisting for all types
of surgical procedures, working in collaboration with
the surgeon as the surgical assistant, and assisting
anesthesia and nursing. The presence of an additional
license may permit other APN privileges to be included
or added to the DOPs, but only if allowed by hospital
policy, department chair approval, or other mechanism identified in the medical staff bylaws or rules and
regulations.
No matter what the formal education, the RNFA also
applies principles of asepsis and knowledge of anatomy, physiology, and operative technique. The RNFA
assists with patient preparation, positioning, prepping,
and draping. In collaboration with the surgeon, using
knowledge, skills, and judgment, the RNFA provides
exposure of the surgical site with the use of retractors,
suction, and sponges. The RNFA can handle tissue,
maintain hemostasis, and perform wound closure.
It is important to review state law to see what level of
licensure the APN RNFA will be held to when strictly
practicing as an RNFA. In most states, the licensee is
held to the highest license he or she possesses.
After surgery, the RNFA helps to transport the
patient and communicates pertinent patient information to the post-anesthetic care unit (PACU), ICU, or
other areas. The RNFA performs postoperative nursing assessments and wound surveillance, educates
the patient or family with discharge planning, and is
involved with patient follow-up care. In addition, the
RNFA may participate in nursing and medical research projects.
© 2013 HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or 978-750-8400.
June 2013 hcpro.com
9
Medical Staff Briefing
Credentialing and privileging the RNFA/APN
The minimum qualifications to practice as an RNFA
include certification in perioperative nursing (CNOR),
successful completion of an RNFA program that meets
the AORN’s “Standards for RN First Assistant Education Programs”; compliance with all statutes, regulations, and institutional policies relevant to RNFAs; and
a baccalaureate degree, with the exception that RNFAs
practicing prior to January 1, 2020, may continue to
practice at their existing level of education. If the RNFA
also has a master’s or doctorate degree and is licensed
as an APN, then all of those credentials must be included in the application packet.
Continued competency
The RNFA, regardless of whether he or she is an
APN, must demonstrate behaviors that progress on
a continuum from basic competency to excellence
and maintain CNOR status. He or she is also encouraged to achieve and maintain RNFA certification
when educational and experiential requirements
have been met.
Clinical privileging for the RNFA
The facility in which the individual practices should
establish a process to grant clinical privileges to the
RNFA. This should include mechanisms for verifying
the RNFA’s qualifications with the primary sources,
evaluating current and continued competency in the
RNFA role, assessing compliance with relevant institutional and departmental policies, defining lines of accountability, incorporating peer and/or faculty review,
validating continuing education relevant to the RNFA’s
practice, and verifying the RNFA’s physical ability to
perform the role.
Activities and privileges
The list of activities defined by AORN may be superseded by a list of activities defined in the nursing scope
of practice for each state.
RNs practicing as first assistants in surgery are functioning in an expanded perioperative nursing role. First
assisting behaviors are further refinements of perioperative nursing practice and are ­executed within the context
of the nursing process. These behaviors include certain
delegated medical functions that can be assumed by the
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RNFA. RNFA behaviors may vary depending on patient
populations, practice environments, services provided,
accessibility of human and fiscal resources, institutional
policy, and state nursing regulations.
The medical staff office personnel need to consult
with their state’s board of nursing to determine if there
is a definition of the RNFA role or a description of
accepted activities within the state’s nursing scope of
practice. The amount of detail varies from state to state,
with some states, such as Hawaii, Kansas, Indiana,
Maryland, Missouri, Minnesota, Michigan, Utah, and
Pennsylvania, remaining silent. This may make things
difficult in privileging the RNFA who is also an APN.
It is imperative that RNFA DOPs are used for primary
privileges and that additional privileges are added as
needed or determined by hospital policy, department
chair, or state law.
The medical staff office at every facility needs to be
sure it has a clear credentialing process that involves the
chief nurse executive since the RNFA and APN remains
under the jurisdiction of the board of nursing in every
state. Moreover, the DOPs need to reflect AORN and/or
state law regarding what the RNFA may perform in that
specific facility.
According to AORN, RNFA behaviors and privileges
in the perioperative arena include but are not limited
to the areas of preoperative, intraoperative, and postoperative management. Preoperative patient management may occur in collaboration with other healthcare
providers while performing focused preoperative
nursing assessments. Intraoperative performance may
include surgical techniques such as using instruments
and medical devices, providing surgical site exposure,
handling and/or cutting tissue, providing hemostasis,
and suturing. Postoperative patient management includes collaboration with other healthcare providers in
the immediate postoperative period and beyond, such
as participating in postoperative rounds, assisting with
patient discharge planning, and identifying appropriate
community resources.
Conclusion
Understanding the RNFA scope and qualifications to
practice permits a clearer view of the face of this
midlevel practitioner, even when the applicant ­presents
with an APN license. H
© 2013 HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or 978-750-8400.
Medical Staff Briefing
Maximizing your interviewing skills
Represent yourself in the best possible light
by Kathleen Tafel, manager of medical affairs and
professional credentialing at St. Clair Hospital in
Pittsburgh
Credentialing and medical staff services professionals are found in a diversified and vast number
of environments: insurance, hospitals, physician
offices, surgical and ambulatory care centers, and
more.
Each one of these environments exposes the
­credentialing professional to a wide variety of potential job tasks. Some may only require a fraction
of the professional’s credentialing skill set: perhaps
just licensure, education, and ­databank searches.
Other positions might task the professional with a
full complement of duties, which could ­include all
regulatory requirements as well as several “office”
tasks, such as call schedule development, accreditation ­standard interpretation and implementation ...
the list goes on.
When interviewing, as the applicant, you will want
to represent yourself and your qualifications in a way
that matches up with how the entity delegates its
credentialing ­responsibilities, as well as the role that
you will play in day-to-day tasks if accepted for the
position.
As such, it’s paramount to consider the experience
you’ve already had and the experience you desire when
searching for a position that’s right for you.
Remember, you will be interviewing the entity as
much as the entity is interviewing you. If you have
a particular interest in expanding your exposure to
­accreditation standards and bylaws interpretation, for
example, voice your enthusiasm for these topics. On
the other hand, if you are not interested in these things
and the interviewer makes clear that the position will
deal with them, then be honest with yourself. If you
were to accept the position regardless, your work would
be a daily struggle; the accountability and the scope of
the position is not going to change.
All credentialing professionals bring value to
their organization. We have transitioned from
focusing on task-oriented skill sets and now have
credentialing roles with larger, “big picture” responsibilities: partnering with managers, directors,
quality ­professionals, and physicians to ensure an
integrated process that results in the delivery of
quality care.
Find and know your niche. Credentialing is a
vast field—identify what you are good at doing, what
you have been successful at, and what you are interested in learning more about and taking on in the
future.
A successful professional transition depends
upon personal honesty and introspection. Celebrate
yourself by shooting for—and hopefully acquiring—
the position that you determine is the best match
for you.
Until next time: “Believe in what you do and do what
you believe.” H
We’re seeking experts for books,
audio conferences, & seminars
Writing books and speaking during audio conferences and
at seminars are great ways to share your industry knowledge
with peers. With the guidance of a solid publishing company,
you’ll see your thoughts and tips become beacons to others in
your field.
We’re always looking for new authors, speakers, and
­reviewers, and we offer competitive compensation. For
more than 20 years, HCPro has been a leading ­provider
of ­integrated healthcare information, education, ­training,
and ­consulting products. Among HCPro’s need-to-know
­information products are a vast array of books, newsletters,
websites, and annual broadcast and live events.
Contact me at [email protected] and let me know
your areas of expertise and interests in publishing or ­training.
Please do not send unpublished manuscripts or specific
­proposals for future works.
© 2013 HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or 978-750-8400.
Matt Phillion
Senior Managing Editor
June 2013 hcpro.com
11
Medical Staff Briefing
MS governance: Myths & ­misconceptions
Myth #6: The tangled web of membership and rights/responsibilities
by William K. Cors, MD, MMM, FACPE
A tangled web is created by inappropriately intertwining stand-alone factors. Physician leaders must
understand the difference between the following elements or risk unnecessary confusion:
• Membership: Fundamentally, medical staff
membership makes one a part of the medical staff organization. It involves the part of the ­credentialing process
that assesses and verifies current licensure, education,
relevant ­training, character, ethics, and behavior.
• Privileges: Clinical ­privileges delineate what a
practitioner can do while utilizing the services and facilities of the ­hospital. ­Additional information is collected to verify ­experience, ability, and current competence,
which is a ­fundamental accreditation standard.
• Membership and privileges: Can you
have membership without privileges or vice ­versa?
The ­answer to both is yes. Membership without privileges is increasingly used to address the conundrum
of low- or no-volume primary care physicians who no
longer admit patients but wish to maintain a connection with the hospital for social, professional, or insurance purposes. Privileges without membership is
also commonly seen in many medical staffs to address
telemedicine practitioners and low-volume physicians
(e.g., gynecological oncologists) who are active at another hospital and whose services are desired by the
privileging hospital and its medical staff. Many medical staffs do the same for advanced practice professionals (e.g., physician assistants, advanced practice
nurses), but they can just as easily have membership.
• Staff categories: Medical staff categories are
not mandated, but they are often used to delineate the
citizenship status of practitioners, including who can
vote and hold office. They can also differentially assign responsibilities, such as emergency department or
clinic coverage, but this practice should be avoided.
According to the famous architect, Louis Sullivan,
form should follow function. The medical staff needs
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hcpro.com June 2013
to decide how it wishes to function and then design the
form (bylaws, staff categories, etc.) accordingly. For
example, the medical staff may want to be “exclusive,”
limiting voting to practitioners with both membership and privileges, or “inclusive,” extending the vote
to practitioners with membership but no privileges
(e.g., community primary care physicians).
Many medical staffs do not extend the vote to
­practitioners who have privileges without membership (e.g., ­telemedicine). The staff categories might
not mention voting at all but simply define “active
staff” (membership plus privileges plus “x” level of
patient contacts) and “­associate staff” (everyone else).
Or, voting rights could be independent of staff categories and extended to practitioners with membership
(with or without privileges). Alternatively, three staff
categories could be used: “active staff” (membership
plus privileges plus activity; can vote), “community
staff” (membership but no privileges; can vote), and
“associate staff” (privileges but no membership; cannot vote). Understanding these elements gives the
medical staff flexibility to thoughtfully address function and design.
• Medical staff rights and responsibilities:
Best practice is to have a separate section in the bylaws outlining both medical staff rights and responsibilities. Many medical staffs instead try to parse
out differential rights and responsibilities through
staff categories. This often leads to practitioners
seeking to switch staff categories to “game the system” and shirk call or other responsibilities. A simple independent responsibility statement could be
“each member of the medical staff must help the
hospital meet its mission to provide emergency services by taking call in the emergency room in accordance with policies passed by the medical executive
committee and the board.”
Next month, we will embark on another area of
interest: the culture of safety and the high-reliability
organization. Until then, be the best that you can be. H
© 2013 HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or 978-750-8400.